HSE Tobacco Free Ireland Programme

HSE Tobacco Free Ireland Programme

HSE Tobacco Free Ireland Programme

HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Implementation Plan 2018-2021

HSE Tobacco Free Ireland Programme

1 HSE Tobacco Free Ireland Programme Table of Contents Glossary X Foreword X Introduction X Context for Action X Strategic Direction X Targets and Outcomes 2018-2021 X AND Assistant National Director CHO Community Healthcare Organisation CYPSC Children & Young Peoples Services Committees DoH Department of Health EH Environmental Health GNTH Global Network of Tobacco Free Healthcare Services HG Hospital Group HIQA Health Information & Quality Authority HP&I Health Promotion and Improvement HI Healthy Ireland HR Human Resources HSE Health Service Executive KPI Key Performance Indicator MH Mental Health MN-CMS Maternal and Newborn Clinical Management System NBSMS National Behavioural Support Management System NCEC National Clinical Effectiveness Committee NMBI Nursing and Midwifery Board of Ireland NSP National Service Plan SP&T Strategic Planning & Transformation TFC Tobacco Free Campus TFCP Tobacco Free Campus Policy TFI Tobacco Free Ireland TFIPG Tobacco Free Ireland Programme Group TUSLA The Child and Family Agency (Tús Lá) Glossary

HSE Tobacco Free Ireland Programme

2 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme The HSE is committed, under Action 4.5 of the Health Service Reform in Healthy Ireland, to “establish multi-disciplinary national teams within Strategic Planning and Transformation to lead and take responsibility for policy priority areas such as Tobacco Control, Healthy Eating and Active Living (HEAL), Healthy Childhood, Alcohol, Wellbeing and Mental Health, Positive Aging and Sexual Health. The priority groups will ensure appropriate governance across the organisation for these areas and ensure that the priorities in the Healthy Ireland Implementation Plan are delivered effectively.

The establishment of Hospital Groups and Community Healthcare Organisations (CHOs) and more recently the appointment of a Health and Wellbeing Head of Service to each of the CHO areas will facilitate the work of the Priority Programmes. This will help to ensure that Healthy Ireland (HI) priorities are delivered across the HSE through a collaborative approach which in turn will provide a more integrated service with better outcomes for service users.

The main aim of the new Tobacco Free Ireland Programme is to take responsibility for and systematically drive policy priorities in the area of tobacco control across the HSE. Ms. Martina Blake has been appointed as lead to the Tobacco Free Ireland Programme. Foreword

HSE Tobacco Free Ireland Programme

HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme 3 The Tobacco Free Ireland Policy Priority Programme was established in late 2016 as part of the Healthy Ireland in the Health Services Implementation Plan.1 It has a remit to: “mobilise the health services to improve health and wellbeing and play its part in the achievement of a reduction in smoking prevalence to less than 5% of the population by 2025”.

The Programme (Appendix A) works to coordinate and lead tobacco control activity across the health services to ensure implementation of the HSE actions contained within the Government Tobacco Free Ireland2 strategy.

1 Healthy Ireland in the Health Services National Implementation Plan 2015 – 2017, Health Service Executive, 2015. 2 Tobacco Free Ireland: Report of the Tobacco Policy Review Group, Department of Health, 2013. This national implementation plan (2018-2021) sets out the HSE strategic direction and priority actions to achieve this. The objectives of the Tobacco Free Ireland Policy Programme over the next four years are to: â Prioritise the protection of children in all of our initiatives and contribute to the denormalisation of tobacco use for the next generation â Support people to quit and treat tobacco dependence as a health care issue â Monitor, build and maintain compliance with tobacco legislation Introduction

HSE Tobacco Free Ireland Programme 4 Tobacco use is the leading cause of preventable death in Ireland with 5,800 smokers dying each year from tobacco related diseases. Smoking related deaths are mainly due to cancers, chronic obstructive pulmonary diseases (COPD) and heart disease. Cigarettes contain over 7000 toxic chemicals, many of which are proven to cause cancer. Smoking harms almost every organ of the body, causing many different illnesses and diseases. A long-term smoker has an average life expectancy of approximately, 10 years less than a non-smoker. The younger you are when you start smoking, the more likely you are to smoke for longer and to die early from smoking.

The Healthy Ireland Survey taken in 20173 reported a smoking prevalence of 22%, 18% daily smokers and a further 4% occasional smokers. While we have seen a reduction in youth initiation from 12.3% in 2010 to 8.3% in 2014 among the 10-17 age group (ref) there is a high level of smoking among young adults with one in every three 25-34 year olds currently smoking. 3 Healthy Ireland Survey 2017: Summary of Findings, IPSOS MRBI, 2017.

4 An Assessment of the Economic Cost of Smoking in Ireland, ICF International, 2016. Tobacco related morbidity and mortality accounts for over 200,000 hospital episodes annually with the total cost to the health service estimated to be over €460 million. The total estimated cost of lost productivity is over €1 billion. This comprises productivity lost through smoking breaks, smokers taking additional absence from work and the premature death of employed workers. The largest proportion of the lost productivity from smoking is estimated to be from the premature death of employed individuals.4 There is an ever increasing recognition among policy makers and health service managers/ service providers that we need to reorient our health services towards prevention of tobacco related chronic disease as these are the major drivers of healthcare costs.

Context for Action

HSE Tobacco Free Ireland Programme Smoking in Ireland Statistics Smoking Prevalence (Ref: Healthy Ireland Survey 2017) Prevalence by Age (Ref: Healthy Ireland Survey 2017) Daily Exposure to Second Hand Smoke (Ref: Healthy Ireland Survey 2017) Age Category (Years) 22% 27% 18% daily 4% occasionally Ex-smokers Ireland now has more quitters than smokers *Worth noting that one in three 25-34 year olds. Smokers Non-Smokers 20% VS 19% 34% 24% 21% 20% 16% 9% 15-24 25-34 35-44 45-54 55-64 65-75 75+ 5 Population are exposed to second hand smoke on a daily basis 10% 16% 34% 25%

HSE Tobacco Free Ireland Programme 6 Attitudes to Quitting (Ref: Healthy Ireland Survey 2017) (Ref: Youth Smoking in Ireland, 2018) Interactions with Healthcare Professionals (Ref: Healthy Ireland Survey 2017) Attitude â 57% of current smokers are thinking about quitting â Smoking rates are higher in more deprived areas than more affluent ones. 32% of those living in the most deprived areas are current smokers, compared to 16% of those living in most affluent areas â Current smokers were over 70% more likely to report distress indicative of probable mental health problems, compared to non-smokers, independent of age, gender and social class â 47% of all who have smoked in the past 12 months have made a quit attempt 12% Other Healthcare Professional Discussed Smoking with a Healthcare Professional in the last year Nurse 22% Dentist 20% GP 35% Hospital Doctor 25% Pharmacist 10% Actively planning to quit Not thinking about quitting Thinking about quitting 42% 57% 13% 16% 28% Thinking about quitting but not planning to Trying to quit

HSE Tobacco Free Ireland Programme 7 Roll Your Own (RYO) Cigarettes (Ref: Roll Your Own Report, 2017) Age Group 2003 2014 3.5% 24.6% â Proportion of smokers using RYO cigarettes has increased from 3.5% in 2003 to 24.6% in 2014. â Those under 25 years of age are three times more likely to smoke RYO cigarettes compared to those aged over 25. E-cigarette Usage (Ref: Healthy Ireland Survey 2017) 7% Use Currently 40% Previously Used Among Smokers Among Ex-Smokers 7% Use Currently 9% Previously Used

HSE Tobacco Free Ireland Programme 8 €256m Primary Care 44% Cancers Cost to Health Services Cause of Death €460m €1.6bn €9bn Health Service Exchequer Loss of Welfare from Morbidity & Mortality Disease Burden (Ref: Nash et al.

Literature Review) Tobacco Related Mortality Financial Burden of Tobacco Use in Ireland (Ref: ICF Economic Assessment, 2016) 1% Digestive Diseases 25% Respiratory Diseases 30% Cardiovascular Diseases Tobacco Free Ireland Strategy (Ref: Tobacco Free Ireland 2013) 1 Provide leadership – policy, practice and clinical 2 Protect children through denormalisation of tobacco use and promotion of tobacco free environments 3 Regulate the retail environment and monitor legislative compliance 4 Treat tobacco dependence as a care issue 5 Monitor tobacco use and prevalence and evaluate the effectiveness of interventions €171m Hospital Inpatient Admissions €13m Hospital Day Case Appointments €15m Hospital Outpatient Appointments €10m Hospital Emergency Department Attendances Five Key Areas for Action

First try ‘Social’ smoker Adult non-smoker Regular smoker Adult smoker Cessation Resumption of smoking Family influences Personal beliefs and values ENVIRONMENT EXTRINSIC FACTORS INTRINSIC FACTORS Psychosocial influences Personal physiological factors Community norms â Exposure to tobacco marketing â Images of smoking in popular media â Tobacco industry â Access â Price â Parental smoking â Sibling smoking â Parental values and attitudes re smoking â Socio-economic status â No risk in trying â It won’t happen to me â Curiosity â Individual choice â Adulthood aspirations â Perceptions of smoking norms â Risk-taking propensity â elf-esteem/self-image â Peer affiliations and friendships â Connectedness to school and/or home â Sense of alienation â Genetics â In utero exposure â Puberty and adolescence â Adult smoking prevalence â Restrictions on smoking â Attitudes to youth and youth culture â Socio-economic and cultural context Tobacco environment Experimentation 9 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme A range of socio-demographic, environmental, behavioural and personal indicators predict the likelihood of adopting or rejecting smoking, particularly in early adolescence (90% of initiation to adult smoking commences in adolesence (ref)).

A decision to smoke leads to trialling the behaviour, and the resulting experience is mediated by each of the three major streams of influence – the personal, the social setting and broader expectations and attitudes.

Determinants of Smoking

HSE Tobacco Free Ireland Programme 10 Improving the health and wellbeing of Ireland’s population is a national priority and a key element of healthcare reform. As part of this reform and in response to an unsustainable level of chronic disease among our population, the Healthy Ireland (HI) Framework was adopted by the Irish Government in October 2013. The Healthy Ireland Framework draws on existing policies but proposes new arrangements to ensure effective cooperation, collaboration, to implement evidencebased policies at government, sectoral, community and local levels.

It is about each individual sector helping to improve health and wellbeing, multiplying all efforts and delivering better results. It proposes a necessary shift towards a broader, more inclusive approach to governance for health, moving beyond the health service, across national and local authorities, involving all sectors of society, and the people themselves. Healthy Ireland describes supportive mechanisms to ensure effective co-operation between the health sector and other areas of Government and public services concerned with social protection, children, industry, food safety, education, transport, housing, agriculture and the environment.

The Health Service commitment to the delivery of Healthy Ireland is reflected in its Healthy Ireland Implementation Plans across the CHOs and Hospital Groups. The Strategic Planning and Transformation Office is responsible for driving this agenda across the entire health service. There is an ongoing shift in focus towards a prevention agenda, where all services have a requirement to support people to stay healthy and well, reduce health inequalities and protect people from threats to their health & wellbeing. The vision is to support every individual and sector of society to play their part in achieving a healthy Ireland through; 1.

Reducing Chronic Disease – the biggest risk to our population’s health and our services 2. System Reform – ensuring that we deliver the significant reforms which are underway to support a better health system 3. Staff Health and Wellbeing – ensuring we have a resilient and healthy workforce Tobacco Free Ireland National Policy The Department of Health published the Tobacco Free Ireland Policy in 2013 and is the successor to the previous National Policy Towards a Tobacco Free Society. The policy sets out the plan for the future in achieving the goal of reducing smoking prevalence to less than 5% by 2025.

It is estimated that in order to achieve this target by 2025, in excess of 55,000 smokers will have to quit each year for the next ten years5 . The policy document makes sixty three recommendations for cross governmental and nongovernmental organisations, including a number of recommendations for the health sector. It is about each individual sector helping to improve health and wellbeing, multiplying both our efforts and our results. Strategic Direction

HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme 11 It is recognised that achieving the population level outcomes and targets will be the result of the cumulative impact of the sixty three specified actions in Tobacco Free Ireland. In this context, the Programme will work with a broad range of external stakeholders seeking to minimise the burden of tobacco related morbidity and mortality in Ireland. Engagement and cooperation across departments and sectors to support implementation of all actions in the Tobacco Free Ireland Policy and Action Plans are led by the Department of Health.

The focus for this implementation plan is on the actions that can be delivered by, or whose delivery can be mediated by the health services. The HSE’s contribution to the 2025 goal of less than 5% smoking prevalence will be progressed through the following key areas: â Prioritise the protection of children in all of our initiatives â Denormalise tobacco use for the next generation â Treat tobacco dependence as a health care issue â Encourage, promote and support smokers to quit through our sustained QUIT campaign, development of our cessation services and through comprehensive training for our staff â Continue to implement and maintain our Tobacco Free Campus policies and promote Tobacco Free Environments â Protect service users, staff and the public from the effects of second hand smoke â Monitor, build and maintain compliance with tobacco legislation â Work with our internal stakeholders to monitor the evidence in terms of tobacco control and participate in an active research and survey programme.

â Monitor and evaluate the effectiveness of all HSE interventions This HSE Tobacco Free Ireland strategic Implementation Plan acknowledges that it has a role to play in the delivery of a Tobacco Free Ireland (

HSE Tobacco Free Ireland Programme 12 The principle source of information is the Healthy Ireland Survey, which through repeated cross sectional survey of a representative sample of the population provides for tracking of smoking prevalence, quitting intentionality and quitting behaviour. It provides insights across key population groups, but is not useful for tracking at CHO or HG level.

However, in relation to other areas and population groups, it should be noted that there are limitations to the existing routine information systems that are currently used to report on key aspects of the HSE Tobacco Free Ireland Programme Plan. Regarding smoking in pregnancy, there is currently no routine information system. The Growing Up In Ireland survey has some utility. A new maternity information system combined with a new behavioural management system will help. Likewise, smoking among people with mental health problems is not trackable through routine information. A comprehensive research programme and secondary analysis is useful in that regard and forms part of this programme plan.

Outcome A sustained downward trend in the levels of tobacco use in the general population in children and young people, in pregnancy and those with Mental ill health.

Target Overall Target 5% smoking prevalenace by 2025 as indicated in cross governmental TFI strategy. The HSE does not take responsibility for reaching the 5% target. It is envisaged however that the range of actions outlined within this strategy will contribute to an incremental reduction in smoking prevalence in support of the DOH goal for a Tobacco Free Ireland by 2025. Inputs Output Measures Outcome Measures Baseline (2017) QUIT campaign aimed at overall population awareness and understanding of risks of tobacco and benefits of quitting.

Targeted, dynamic multi-media plan: Monitoring, evaluation and tailoring of messaging, media and timing as required across search, social, digital and traditional media (including public relations) Decrease in prevalence of tobacco use.

22% Increased website visits during active media bursts. Clear tracking of activity. Omnibus and specific research on target audiences where required. October/November 2017 media burst resulted in 89% increase in sessions on QUIT.ie Increase prevalence of positive quit intentions. 57% of smokers are at leastthinking about quitting Increase prevalence of quit attempts particularly among men aged 25-44.

42% of current smokers have made a quit attempt in the past 12 months Ongoing measurement and understanding of QUIT sign ups online. 16,820 during 2017 No. of clients who contact QUIT Freephone. 2,914 during 2017 Visits to website. 245,430 during 2017 Redevelopment of QUIT website Redevelopment of QUIT website in line with HSE digital roadmap and to maximise QUIT sign ups Ongoing measurement and understanding of user experience on QUIT.ie Closed Facebook groups created, piloted, moderated and evaluated Signups to closed Facebook group and completion of closed Facebook programme To be piloted Measureable outcomes

13 HSE Tobacco Free Ireland Programme Inputs Output Measures Outcome Measures Baseline (2017) Introduction of user feedback on QUIT.ie No. of referrals to intensive cessation support by health professionals annually No existing data No. of self-referrals to intensive cessation support No existing data No. of clients receiving intensive cessation support through HSE services 11,952 Brief intervention for smoking cessation through implementation of Making Every Contact Count training No. staff trained in MECC online modules.

No. staff trained in skills to practice module No. non-HSE staff trained No.

undergrad health professional trainees trained No. of clients from specific population groups receiving intensive cessation support through HSE services (Pregnant, those with mental ill health, men, youth and low SES) Increase proportion of clients who discussed a quit attempt with a healthcare professional  to 40% for GPs  to 35% for hospital doctors  to 25% for nurses  to 20% for other health professional No existing data 35% 25% 22% 12% Development of clinical guidelines for the identification, diagnosis and treatment of tobacco dependence Clinical guidelines developed, stakeholder consultation complete, guidelines endorsed by Minister for Health and published Increase in no.

smokers within the last 12 months who have stopped smoking for one day or longer because they were trying to quit 47% of all who have smoked in the past 12 months have made an attempt to quit Reduction in no. people who smoked tobacco products daily and occasionally by 0.5% prevalence per year (interdependent on DoH measures) 18% daily smokers 4% occasional smokers On-going implementation and monitoring of HSE Tobacco Free Campus Policy in HSE services Implementation and on-going monitoring of HSE Tobacco Free Campus Policy in 100% HSE services TFC Policy implemented in 100% Mental Health Approved Centres 100% Mental Health Residential Centres 100% Older Persons Services 100% Disabilities Services 100% Primary Care settings 63% Mental Health Approved Centres 38% Mental Health Residential Centres 63% Older Persons Services 49% Disabilities Services 100% Primary Care Settings On-going monitoring and enforcement of tobacco legislation No.

test purchases carried out % increase in compliance with sale of tobacco products to minors 429 (90% compliance) No. smoke free workplace legislation inspections carried out % increase in compliance with smoke free workplace legislation Youth Initiation and Prevalence Reduction in no. children who have tried smoking 16% Reduction in no. children who have tried smoking monthly or more frequently 8.3%

14 HSE Tobacco Free Ireland Programme Theme 1: Provide Leadership for the implementation of the HSE elements of Tobacco Free Ireland TFI Policy Action Action Identified Proposal for “HOW” this will be met 1.1 1 Support effective implementation of the National Healthy Ireland and Tobacco Free Ireland Action Plan (DoH) and ensure the Tobacco Free Ireland Programme priorities are included in the National Service Plan and relevant annual operational Plans. Tobacco Free Ireland Priority Programme National Implementation Group will identify & agree priorities for National Service Plan/Operational plans and support delivery of same across the CHOs and hospital groups.

1.2 Develop a suite of Key Performance Indicators to: a) Monitor impact of HSE delivered or funded interventions, programmes and services b) Monitor delivery of this Implementation plan Work with Strategic Planning and Transformation and the Performance and Planning Unit and service representatives to propose, review and quality assure NSP, operational plans and KPIs. Examine existing tobacco related KPIs and develop new KPIs to monitor performance. Engage with HI Governance group and HSE HI Office to support inclusion of and delivery of the TFI actions across the CHOs and Hospital groups.

1.3 Identify resource implications to deliver TFI actions contained within this plan. Draft annual PIDs for operational activities and new projects based on programme.

Prepare business cases and funding estimate bids and approve at TFIPG. 1.4 Engage with international health colleagues to share learning and experiences in the implementation of quality standards in relation to tobacco management. Membership of the Global Network of Tobacco Free Healthcare Services (GNTH). Participation in Global Network conferences and forums. Participation in development and hosting of World Conference on Tobacco and Health in 2021 with the DoH. 1.5 10.1 Government Departments and state agencies including the Health Service Executive will continue to liaise and work with non-governmental organisations in order to achieve policy aims set out in this plan.

Ensure on-going engagement via: TACU within the DOH, state agencies and NGOs and the Tobacco Control Partners group.

On-going monitoring of cross governmental strategic public policy consultation processes. Actions, Measures and Deliverables

15 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Deliverables Responsible Time Frame Commence Complete Annual priority actions and key performance indicators identified and agreed and included in the National Service Plan and relevant divisional service operational plans. TFI Programme Team and TFIPG 2018 Annual 2021 Suite of KPIs identified. KPI review and monitoring sub group of TFIPG Group established.

Annually agreed KPIs in NSP and Operational Plans. TFI actions included in CHO and hospital group Healthy Ireland plans.

TFI Programme Team, HI lead, CHO/ Hospital Group representatives 2018 Annual 2021 PIDs drafted for all new tobacco activities annually. Annual funding estimates bid drafted and brought to Leadership/DoH through Planning and Performance. TFI Programme Team 2018 Annual 2021 Participation in or coordination of International tobacco events to support the Tobacco Free Ireland agenda. Participation in international research/events and the GNTH to promote quality standards. TFI Programme Team 2018 Annual 2021 Partners group established under the Tobacco Free Ireland Programme.

Three annual meetings and on-going collaboration.

TFI Programme submits feedback to cross governmental policy consultation processes to embed tobacco control actions in future planning. TFI Programme Team 2018 Annual 2021

HSE Tobacco Free Ireland Programme 16 Theme 2: Protection of children in all of our initiatives, denormalise tobacco use for the next generation and promote tobacco free environments. TFI Policy Action Action Identified Proposal for “HOW” this will be met 2.1 7.1 The protection of children must be prioritised in all of the initiatives outlined in the policy. Work with Tusla to support the development of a policy for the protection of children from second hand smoke in foster care homes and all levels of care. 2.2 7.5 Promote tobacco free campuses for all healthcare governmental and sporting facilities in consultation with key stakeholders.

Work with the DOH and a corporate partner to develop a tobacco free campus toolkit for all types of workplaces. Work with LCDCs and CYPSCs to promote tobacco free public spaces and environments for children. 2.3 7.2 Denormalisation must be a complimentary underpinning theme for all of the initiatives within the policy. Work with the Department of Education and Science and partners to develop the tobacco elements of the revised SPHE junior cycle curriculum. 2.4 7.2/7.5 Engage internally with CHOs/ Hospital groups and externally with relevant stakeholders to ensure that denormalisation is a complementary underpinning theme for all initiatives.

Engage with the Mental Health and Social Care national offices to support the successful implementation of the HSE TFC Policy. 2.4.1 Engage with HIQA and MH Commission in a formal way to lobby for inclusion of TFCP as part of their audit criteria.

17 HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete Engage with TUSLA to advocate that they prioritise the development of a policy to protect children from second hand smoke in all levels of care and support them in this process. TFI Programme Team 2019 2021 Generic Tobacco Free online toolkit developed. TFI Programme Team/DoH 2018 2018 Guidance document developed for LCDCs to promote tobacco free environments, promote denormalisation and signpost to local cessation supports.

TFI Programme Team 2018 2018 Input provided at LCDC forums. 2018 2021 Tobacco elements included in the SPHE junior cycle curriculum.

TFI Programme Team/SP&T Education Programme Manager 2018 2018 TFC targets set and agreed for each service area within each CHO/Hospital group. TFI Programme Team/TFIPG CHO Representative Acute Service Representative/Mental Health Representative/Social Care Representative 2018 2019 Implementation status monitored at service/ operational level. 2018 2021 Guidance tools and resources for implementation in specific service areas developed. 2018 2019 Workshops/conference/events planned & delivered to support quality improvement/monitoring of TFC policy.

2018 2021 HIQA/MH Commission supported to include TFC policy and the treatment of tobacco addiction as part of their audit criteria. TFI Programme Team/Quality Improvement 2018 2018

18 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme TFI Policy Action Action Identified Proposal for “HOW” this will be met 2.4.2 Work with HR to progress tobacco free Ireland objectives. 2.4.3 Develop a tobacco free campus policy communications campaign targeting service users the public and staff. 2.4.4 Work with Quality Improvement/Quality Assurance and Verification to progress and embed TFC policy in their routine audits and their quality improvement processes.

2.4.5 Engage with National Estates Office to incorporate TFC policy provisions in the development of all new sites and buildings.

2.5 9.5 Undertake a social marketing campaign (DOH funding dependent) focusing on the risks to children from exposure to secondhand smoke with particular reference to smoking in cars. Communications to review social marketing campaign developed in relation to second hand smoke (SHS). 2.6 Engage with partner agencies and youth organisations to address tobacco control among youth. Work with partner agencies i.e. Spunout and ICS to develop targeted tobacco control programmes to support cessation/prevent initiation. 2.6.1 Review and publish ‘Quit 4 Youth’ training resources.

19 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete HR representative nominated to TFIPG.

HR representatives to lead the revision of the National TFC Policy. HSE tobacco free campus policy reviewed, revised and signed off. Communicate the revised policy to all levels of management and staff. SP&T/TFIPG/HR TFI Programme Team/HR/all divisions 2019 2021 Suite of TFC communication tools developed and implemented. Communications/TFI Programme Team/ CHOs/HGs 2019 2021 TFC is included in quality improvement practice/ protocols.

TFC policy implementation is audited either independently or is done as an integral part of a service audit on a two year basis. TFI Programme Team/Quality Improvement/Quality A&V 2020 2021 TFC policy provisions routinely incorporated in new estate projects/public-private partnerships as part of the tender process. TFI Programme Team 2019 2021 Communications will promote the SHS campaign through social media channels. A specific focus will be given to the risks to children from exposure to SHS. Communications 2019 2021 Tobacco content on Spun out website developed and monitored on an on-going basis.

Youth organisations supported to develop a youth tobacco control advocacy forum.

TFI Programme Team/HP&I/Spun out/ICS 2018 2020 Quit 4 youth reviewed and published. Training programme to support resource developed and training delivered. HP&I 2018 2019 2018 2021

HSE Tobacco Free Ireland Programme 20 Theme 3: Legislative compliance and regulating the retail environment TFI Policy Action Action Identified Proposal for “HOW” this will be met 3.1 8.2 Continue to promote compliance with all provisions of the Public Health (Tobacco) Act 2002 as amended particularly the workplace legislation. Identify this action in the HSE Annual Service Plan.

3.2 8.3 Develop capacity within the HSE’s Environmental Health Service to maintain consistent and sustained enforcement of all aspects of the tobacco control legislation. Enforcement, compliance levels & legislative provisions reviewed.

Non-compliant businesses/services targeted. 3.3 9.6 Monitor the effectiveness of the current tobacco free legislation, including the review of existing exemptions and the monitoring of compliance with these provisions. Joint DOH TACU and HSE group to review all tobacco control legislation quarterly. 3.4 8.4 Develop special investigation capacity within the HSE’s Environmental Health Service to assess compliance by tobacco and E-cigarette manufacturers. The reconfiguration of the Environmental Health Service will consider this recommendation. 3.5 9.19 Monitor the implementation of regulations for pictorial warnings.

Joint DOH TACU and HSE group to review all tobacco control legislation quarterly. 3.6 9.22 Review existing legislation to ensure that it is fit for purpose to deal with new and emerging measures and marketing programmes adopted by the tobacco industry. Joint DOH TACU and HSE group to review all tobacco control legislation quarterly. 3.7 9.28 Examine and monitor the existing tobacco legislation to ensure that it is inclusive of contemporary forms of communications. Joint DOH TACU and HSE group to review all tobacco control legislation quarterly.

21 HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete Data to be inserted here.

AND Environmental Health 2018 Annual 2021 Annual review of national enforcement and compliance levels completed. Standard operational protocols reviewed annually. AND Environmental Health 2018 Annual 2021 Convictions published quarterly on the HSE website. AND Environmental Health 2018 Annual 2012 Included as a composite part of the developing National Tobacco Control Operational Unit. AND Environmental Health 2018 Annual 2021 Survey and report on combined warnings on a cohort of cigarettes developed by revenue (illicit trade).

AND Environmental Health 2018 Annual 2021 Follow up of review of EU manufacture, presentation and sale of tobacco and related products complete. Regulations 2016 reviewed and amendments proposed to DOH in order to satisfy the requirements of directive 2014/40/EU. AND Environmental Health 2018 Annual 2021 Legislation reviewed quarterly. AND Environmental Health 2018 Annual 2021

22 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Theme 4: Treat tobacco dependence as a health care issue TFI Policy Action Action Identified Proposal for “HOW” this will be met 4.1 9.7 Identify a lead person with clear lines of responsibility for the coordination of smoking cessation services within the health service to ensure a national approach.

TFI Programme lead to liaise with HP&I to identify a lead for cessation services. 4.2 9.8 Develop comprehensive national smoking cessation guidelines. These to include the minimum level of service provision that each service provider needs to have in place. Complete an assessment of the delivery of tobacco cessation services in HSE and develop a model for service delivery.

4.3 Review existing national standards for the intensive cessation support Programme and publish renewed standards. 4.4 Develop Clinical Guidelines for the Identification Diagnosis & Treatment of Tobacco Dependence. Develop guidelines in line with NCEC processes and publish. 4.4.1 TFI Programme Team to complete clinical guideline training. 4.4.2 Establish a Clinical Guideline consultation group within the HSE and externally. 4.4.3 Prioritisation submission made by Guideline Development Group to NCEC. 4.4.4 Review existing national/international guidelines and draft/adapt or amend for the Irish setting.

4.4.5 Undertake extensive internal and external stakeholder consultation.

4.4.6 Amend guidelines post consultation and submit to NCEC. 4.4.7 Publish endorsed guidelines. 4.5 Develop Implementation and communication plan for the introduction of the final guideline for the identification, diagnosis and treatment of tobacco dependence into the clinical setting. Review national/international implementation plans for other guidelines and draft/adopt or amend for the Irish setting. 4.6 9.11 Train all frontline healthcare workers to deliver interventions for smoking cessation as part of their routine work.

Support the work of the MECC project team through: active participation in MECC oversight group and working groups; providing behaviour change support tools and resources for smoking cessation.

Provide and agree content for MECC tobacco module.

23 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete Lead in Place. HP&I AND 2018 2018 Assessment of tobacco cessation service complete. Model for service delivery for standard service and for services targeted at special interest populations drafted and signed off (Post publication of the Clinical Guidelines for the Treatment of Tobacco Dependence). HP&I supported by TFI Programme Team 2019 2020 Standards reviewed and published. HP&I supported by TFI Team 2019 2020 Clinical guidelines quality assured by NCEC, published and endorsed by the DoH.

TFI Programme Team/Clinical Guideline Development Group 2018 2020 NCEC Clinical Guideline training completed by TFI Programme Team.

TFI Programme Team 2018 2018 Clinical guideline consultation group established and convened. TFI Programme Team 2018 2018 Guidelines prioritised by NCEC. Clinical Guideline Development Group 2019 2018 Existing guidelines critically appraised and draft guideline complete. Clinical Guideline Development Group 2019 2019 Stakeholder consultation completed. Clinical Guideline Development Group 2019 2019 Guideline amended following stakeholder consultation and submitted to NCEC. Clinical Guideline Development Group 2019 2019 Guideline quality assured by NCEC and endorsed by the DoH and Minister for Health.

Clinical Guideline Development Group 2019 2020 Implementation and Communication plan drafted. TFI Programme Team/Clinical Guideline Development Group/Communications 2019 2019 Tobacco Knowledge Reference Group established. Participation in MECC oversight group. HP&I TFI Lead 2018 2018 2018 2020 MECC tobacco module developed, piloted, amended and launched as part of MECC training suite. TFI Programme Team/HP&I 2018 2018

24 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme TFI Policy Action Action Identified Proposal for “HOW” this will be met 4.6.1 Agree brief intervention training/MECC targets annually in consultation with oversight group and TFIPG. Continue to train health professionals in smoking cessation. 4.6.2 4.6.3 4.7 9.9 Undertake targeted approaches for specific groups (C2DE), particularly young people, lower socioeconomic groups, pregnant and post-partum women and patients with chronic disease disorders to treat tobacco dependence.

Develop intensive cessation services which target specific population groups: Work with the Women and Infants Programme (W&IP) to develop and agree evidence based tobacco control actions to be included in the W&IP Action Plan.

4.7.1 Services targeting pregnant and postpartum women Work with the HI hospital group managers/Primary Care and the Woman and Infants Programme to advocate for the establishment of onsite cessation services in maternity settings across Acute and Primary Care services. 4.7.2 Work with the chronic disease clinical lead/project manager for maternity system to advocate for risk recording to be included in the new maternity IT system (MN-CMS).

4.7.3 Work with Maternity services to bring about routine carbon monoxide monitoring (CO) and referral at specific antenatal contacts/visits. 4.7.4 Scope and deliver an action research project across primary care and acute maternity services to examine the effectiveness of routine CO monitoring and intensive cessation provision/ Incentivised Quit.

25 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete Targets agreed and included in NSP. HP&I and TFIPG 2018 Annual 2021 Health professionals trained to deliver brief interventions for smoking cessation as part of MECC training.

HP&I 2018 Annual 2021 Tobacco content incorporated in to Chronic Disease Prevention Module for all undergraduate/ postgraduate health professional courses. TFI Programme Team/HP&I/Clinical Strategies and Programmes 2018 2019 Continue to train a variety of staff as intensive smoking cessation specialists.

HP&I 2018 2021 Specific tobacco actions included in the W&IP annual programme of work. TFI Programme Team/HP&I 2019 Annual 2021 Establishment of new maternity onsite cessation services/referral pathways (funding dependant). Provide guidance and training to maternity units to establish services according to the HSE Standard Treatment Programme. Staff trained in MECC and in the specialist cessation module for pregnancy. HP&I/TFI Programme Team/W&IP 2019 2021 Risk recording for tobacco prevalence and treatment included in MN-CMS. TFI Team/HP&I/CS&P, IT, OOCIO/W&IP 2018 2018 Advocate for routine CO monitoring to be embedded in routine antenatal service.

Maternity hospital networks supported to train midwives in the completion of CO monitoring. TFI Programme Team/HP&I W&IP/CS&P 2019 2021 Business case complete and approved. Project initiated and evaluated. W&IP/HGs/TFI Programme Team/HP&I 2019 2021

HSE Tobacco Free Ireland Programme 26 TFI Policy Action Action Identified Proposal for “HOW” this will be met 4.7.5 Services targeting smokers with Mental ill-health Work with MH national office/CHOs to implement and monitor TFC policy in MH settings. Work with the Mental Health national office/CHOs/ MH advocacy groups to advocate for and support the development of onsite smoking cessation services across acute and community mental health services. 4.7.6 Services targeting smokers in lower socio economic groups Work with ICS to progress the implementation of the ‘We Can Quit’ cessation programme targeting women in lower socio economic groups.

4.7.7 4.7.8 4.7.9 Review QUIT campaign to realign media buy to target more effectively specific hard to reach population groups. Continue to set specific targets and monitor throughput of hard to reach population groups to intensive cessation services through the NBSMS. 4.8 Services targeting smokers with existing chronic disease Explore with the Office of Nursing and Midwifery Services opportunities to progress nurse prescribing of tobacco dependence treatments. 4.9 Establish a national database for the collection and collation of data from all smoking cessation services.

Develop and implement a Patient Management System (NBSMS) for services to standardise data collation and facilitate electronic referral to improve efficiencies.

27 HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete Tobacco Free Campus policy implemented in all mental health settings. Routine monitoring of tobacco free campus and quality improvement processes established in MH. New mental health onsite cessation services/ referral pathways established. Mental Health National Office/TFI Programme Team/HP&I CHO/HP&I CHO/HP&I 2018 2021 Support delivery of the “We Can Quit” Programme through HSE staff and sourcing suitable locations/ HSE venues.

ICS, HP&I/Trinity/TFI Programme Team/ Communications 2018 2020 Support the planning and running of a randomised cluster pilot trial of “We Can Quit”.

HP&I/TFI Programme Team 2018 2021 ‘We Can Quit’ pilot trial complete and report drafted. ICS, HP&I/Trinity TFI Team 2018 2020 QUIT campaign continually monitored to ensure it is reaching specific population groups of interest. Specific population group targets for intensive cessation services set & NBSMS system monitored to assess performance against targets. Communications/TFIP team/ HP&I TFIP team/HP&I/CHOs/Hospital Groups Tobacco dependence treatments included in the list of medications for chronic disease specialist nurses.

N&MS/TFI Programme Team/NMBI/ Clinical Guideline Development Group/ W&IP 2020 2021 Tender process complete. Contract drafted and signed between HSE and successful provider. IT system developed to the required specification. Pilot site identified to trial new system and one stop referral model. New system integrated in to existing IT systems in acute divisions and Primary Care. Amendments completed to system based on pilot feedback. Three integrations delivered between the new National Behavioural Support Patient Management System; Healthlink, Quit.ie & the MN-CMS. Communications plan developed to promote the one stop referral model to GPs/PC/MH/SC/Acute staff.

New system launched and communicated. TFI Programme Team HP&I/Procurement External Provider/HP&I/ Comms/Relate Care 2018 2019

28 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Theme 5: Monitor tobacco use and prevalence and evaluate effectiveness of all interventions TFI Policy Action Action Identified Proposal for “HOW” this will be met 5.1 9.2/9.3 Tobacco control measures should be continuously evaluated to ascertain impacts and outcomes. On-going surveillance of tobacco use through HSE Tracker Survey, Healthy Ireland and Health Behaviour in School Children Surveys. Publish first and second HSE State of Tobacco Control Report.

5.1.1 Work with services/divisions to agree targets for completion of GNTH global online self-audit.

5.2 9.20/9.3 Tobacco control measures should be continuously evaluated to ascertain impacts and outcomes including the evaluation of campaigns and programmes. Evaluation built in to the QUIT campaign and cessation service provision and carried out as appropriate. 5.2.1 Work with quality improvement and quality assurance and verification division to progress quality improvement in terms of TFCP implementation and the treatment of tobacco dependence. See Action 8.3/8.4/9.19/9.28. 5.2.2 Evaluation of cessation/Quit services. Monitor throughput, reach of tobacco users through National Health Behavioural Management System.

5.2.3 Evaluation of BISC training effectiveness.

29 HSE Tobacco Free Ireland Programme HSE Tobacco Free Ireland Programme Deliverables Responsible Timeframe Commence Complete Secondary analysis of tobacco indicators from HI survey, HBSC and TILDA published to build evidence for TFI. TFI Programme Team/Public Health/ Health Information Unit 2018 2018 State of Tobacco Control in Ireland Report produced in 2018 and 2021. 2018 2021 Develop and publish HSE tobacco control research and information plan (2019.) 2019 2021 Implement HSE tobacco control research and information plan (2020-2021).

2019 2021 Targets for GNTH self-audit drafted and embedded in CHO/Hospital Group Healthy Ireland Plans. Annual collation of data on the number of selfaudits completed. TFI Programme Team/CHOs/Hospital Groups 2018 2021 Completion of monthly evaluation of digital display media. Completion of quarterly web statistics using Google analytics. Completion of You-tube tracking. Quarterly analysis of conversion rates from digital partnerships. Completion of quarterly and annual audit on media spend. Completion of Quarterly tracking of media coverage measurements.

Completion of monthly audit of cessation service provision against target.

Completion of omnibus research awareness to monitor campaign awareness and effectiveness. Completion of monthly evaluation of social media engagement. Communications/HP&I/TFI Programme Team 2018 On-going - 2021 Quality improvement guidance received on TFC implementation. TFI Programme Team/HP&I 2019 2020 Monthly performance reports on throughput and reach of cessation services drafted. HP&I/Communications/TFI Programme Team/ICT 2018 2021 BI training evaluation complete and report published.

TFI Programme Team 2018 2018

HSE Tobacco Free Ireland Programme 30 Tobacco Free Ireland Programme Group (TFIPG) An Implementation Group entitled the “Tobacco Free Ireland Programme Group” (TFIPG) has been set up under the Tobacco Free Ireland Programme, chaired by Ms. Martina Blake, Tobacco Free Ireland Programme Lead. The group has clear terms of reference which will provide strategic direction for the work of the Programme, monitor progress and facilitate effective co-operation between service areas. Membership of the implementation group includes senior management from each HSE service area, the Hospital Groups and Community Healthcare Organisations who have responsibility for the delivery of agreed actions within their respective services at both a national and local level.

Programme Team (2018) Role Name National Lead Martina Blake Project Manager Edward Murphy Tobacco Free Campus Policy Lead Miriam Gunning Administrator TFI@hse.ie Clinical and Research Lead Dr Paul Kavanagh Communications Campaign Manager Aoife O’ Sullivan Rachel Wright Tobacco Free Ireland Programme Group (TFIPG) Membership Service Areas Represented 2018 National Lead, Tobacco Free Ireland Programme Project Manager, Tobacco Free Ireland Programme Tobacco Free Campus Policy Lead, Tobacco Free Ireland Programme Clinical and Research Lead, Public Health/Tobacco Free Ireland Programme HSE Communications Health Promotion and Improvement National Office Healthy Ireland National Office Lead HSE Human Resources Social Care – Disability Services Social Care – Older Persons Services Mental Health Primary Care National Acute Hospitals Office Hospital Groups Community Healthcare Organisations Environmental Health TUSLA National Behavioural Support Management System Project Manager National Cancer Control Programme Appendix A

31 HSE Tobacco Free Ireland Programme Tobacco Free Ireland Partners Group Partnership Working/Stakeholder Involvement Healthy Ireland places significant emphasis on collaboration and partnership working. The achievement of our strategic priorities is dependent on effective partnerships internally and strong cross-sectoral engagement with external stakeholders. In some instances other agencies and government departments are better placed to deliver on actions which impact on people’s health and wellbeing – we must proactively leverage existing relationships and forge new relationships in pursuit of our shared agenda.

The Tobacco Free Ireland Partners Group is a multiagency partnership made up of representatives from across non-government organisations with an interest in Tobacco control. The aim of the group is to provide a formal platform for discussion and dialogue between the HSE and non-governmental stakeholders on tobacco control. Ideas and best practice can be shared in relation to tobacco control issues. This multi-agency working group will also help drive, co-ordinate and support the delivery of the priorities in the Tobacco Implementation Plan. Tobacco Free Ireland Partners Group Membership Alpha 1 Foundation Tobacco Free Ireland Programme, HSE (Chair) ASH Ireland Asthma Society of Ireland Athlone Institute of Technology Communications, HSE COPD Ireland Environmental Health, HSE Health Promotion and Improvement, HSE Institute of Public Health Irish Cancer Society Irish College of General Practitioners Irish Dental Association Irish Heart Foundation Irish Thoracic Society National Cancer Control Programme National Women’s Council of Ireland Pharmaceutical Society Of Ireland Public Health, HSE Royal College of Physicians Ireland SputOut Tobacco Free Research Institute Appendix B

HSE Tobacco Free Ireland Programme
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